Female Hair-loss

Hair-loss in men is something that we are now comfortable talking about. But hair-loss in women is, regrettably, a more taboo subject. However, it won’t stay that way, as increasing numbers of women seek a solution to their all-too-common problem.

And as techniques for addressing hair-loss become more sophisticated and more design-led, there is now a growing understanding that hair-loss [and its associated difficulties for women] is a problem we can do something about.

Alongside this, Paradigm clinic is aware that female hair-loss often carries with it a very significant undermining of self-esteem - and we take this into account when working with our patients.

Crucially, a female hair line is not the same as a male hair line. And because of this, it is very important that transplants for female patients are designed to take into account the greater complexity and variation in their hair lines. Quite literally, this is not a straight-forward matter as female hair lines display a pattern of variation that male hairlines simply do not.

Moreover, many of the non-surgical treatments for men have differing outcomes and side effects in women and are therefore not-suitable to be prescribed or used in the same way.

It may be unfashionable to say that men and women are very different, but when it comes to hair-loss treatment and management, it is indisputably the case. Therefore clinicians need particular experience of working with female patients and transplanting the complicated female hair lines so that appearance can be enhanced in a skillful, experienced and knowledgeable way.

Our personal experience of this common condition is reflected in the scientific studies which show that female pattern hair-loss can occur in up to 20 to 30%of the female population1.

While hair-loss occurs in up to 50% of the male population, hair-loss is a variant and accepted norm for many men. On the other hand, hair-loss for females is not considered ‘normal’ and hence the devastating psychological effects when it does occur.

The most common hair-loss type is often seen as a facet of the aging process and is more properly termed Female Pattern Hair Loss (FPHL).

Female pattern hair-loss (formerly female androgenetic alopecia), is primarily a genetic condition arising from many different genes - hence its unpredictable nature.

Many cases often arise as the first-affected member of a family, that is to say, with no clear prior family history.
Some studies have identified a number of possible risk factors for patterned hair-loss including;

  • increased weight
  • diabetes
  • lower number of births
  • hirsuitism
  • polycystic ovarian disease (PCOD)

Female pattern hair-loss does, however, present in a different fashion compared to male pattern hair-loss. While male pattern hair-loss demonstrates characteristic recession and complete loss of hair in the temples and/or crown, in female pattern hair-loss there is a definite preservation of the hairline position, but there is nevertheless a diffuse thinning process within and behind the hairline.

Like male pattern hair-loss, there is also preservation of hair density in the occipital region, that is, on the back of the scalp. This preservation of hair at the back is exploited in the hair transplantation process by ‘moving’ hair from the scalp at the back to the front.

This female pattern of hair-loss has been characterized in the classifications [seen below] and, as one can see, there can be the gradual reduction in follicle density which can ultimately lead to complete loss of hair. Although this is very rare.

Female pattern hair-loss management

Female patients presenting with thinning hair should seek consultation with a consultant such as myself, who will conduct a thorough medical history and physical examination. This will assist in establishing a diagnosis of the potential causes of the hair-loss.

Other common potential diagnoses of hair-loss include; the inflammatory alopecias (e.g. alopecia areata) and chronic telogen effluvium. It is often useful to have baseline blood tests carried out at some stage including serum ferritin and iron levels, thyroid function, blood glucose and auto-antibody screens.

Depending on the clinical indicators, a scalp biopsy may also be necessary. In the majority of cases a clinical diagnosis can be established on history and examination alone. The commonest cause of hair-loss is thus Female Patterned Hair Loss (FPHL).

Surgical management (transplantation)

With the limited benefits of medical management (see below), hair transplantation is the mainstay of treatment for female pattern hair-loss.

The principles of surgery remain the same as with male patients in that one is transferring hair from an area of the scalp that is refractory to the hair-loss process to the areas of greatest hair thinning - thus yielding a cosmetic benefit.

In our experience, the FUE transplantation technique has significant benefits in that there is rapid donor site healing and very little chance of shock-loss in the donor site hair. Indeed we have never come across significant problems with the FUE technique.

The primary goal with many female pattern hair-loss patients is their thinning hairline, thus the hairline design and technical execution of the transplantation procedure is an extremely rigorous process if a natural hairline is to be recreated.

This is a particularly complex business as a female hair line is not the same as the hairline in men.

At Paradigm, we pride ourselves in this area of work having looked after many female patients over the years.

As the physiological/genetic predisposition to hair-loss has not been altered with transplantation (ie the thin areas have been ‘filled in’), patients will thus benefit from medical treatment to the non-transplanted hair to slow down this hair-loss over the years.

An on-going relationship with a clinic is ideal so that treatments can be fine-tuned according to an individual’s hair-loss progress over time.

Summary points

  • Transplantation is the most beneficial treatment for female hair-loss.
  • Transplantation should ideally be supplemented by medical treatment to slow down the loss of the non-transplanted hair.
  • Treatment is a bespoke process potentially over many years and changing depending on hair-loss progression/type and goals with each individual patient.
  • In our hands, the FUE process significantly minimises the risks of donor site shock-loss and wound healing issues.
  • Hairline design is crucial and often more demanding in the female hair-loss patient compared to the average male patient.

Non surgical management

The patterned hair-loss predisposition itself can be ameliorated with the use of topical treatments. Thus while surgery is often the best means of improving the overall hair appearance (see below) it is best complimented with topical treatments to act on the pre-existing (non-transplanted) hair within the scalp and minimise its potential to fall out in the future.

At Paradigm we feel uneasy about advocating treatments that are of no benefit to a patient and are at least a potential financial risk to the patient. Thus at consultation we can discuss at length those treatments most likely to benefit an individual patient.

a) Minoxidil(Regaine®)

Minoxidil is an anthypertensive medication that serendipitously was discovered to be associated with increased hair growth. It was thus developed into a topical medication to be applied to the scalp directly. Mainstream pharmaceutical manufacturers of Minoxidil produce the solution in either at 5% or 2% preparations. In addition to the 5% preparation can be supplied as a foam which is often preferred by patients as the liquid can make the hair appear greasy.
Some studies indicate that the 5% preparation maybe more effective than 2% variety while other studies however contradict these findings 2,3.

The commonest side-effect for women is the potential for increased mild hair growth on the face and/or hands however this can be minimised through handwashing after application. In addition, it is common for women to complain about hair growth elsewhere if they are seeing benefits within the scalp.

Summary points

  • 5% or 2% concentrations
  • Liquid or foam preparations.
  • Has scientifically been shown to be of value.
  • May increase hair number density by 15% after 3-6 month use.
  • Must be continuously used to maintain results.
  • Side effects include mild hair growth on face /hands.

b) Ketoconazole (Nizoral® shampoo)

Ketoconazole(2%) is produced as a shampoo primarily used for cradle cap or seborrheic dermatitis, and has been shown to be of benefit to male pattern hair-loss 4,5.

As yet there are no well-established studies in demonstrating clear-cut benefit within the female population. The similar pathogenic mechanisms between FPHL and MPHL coupled with the low side effect profile and low expense mean that it may be useful for female pattern hair-loss until definitive evidence is forthcoming.

Summary points

  • Shown to be of benefit in male pattern hair-loss but not yet in female pattern hair loss
  • Used x3 per week as a shampoo
  • Inexpensive
  • Minimal side effects

c) Oestrogen Therapy ( contraceptive pill, hormone replacement therapy)

Presently there is insufficient evidence to support the use of oestrogen therapy for alleviation of hair-loss. There is a complex interplay between the various sex hormones with temporary hair shedding occurring both with institution and cessation of oral contraceptives and hormone replacement therapy.

d) Finasteride (Propecia)

While finasteride has proven to be very successful for the management of male pattern hair-loss it has unfortunately not proven to be of similar benefit with female pattern hair-loss. In addition to this, finasteride is potentially teratogenic i.e. fetal abnormalities could potentially arise and thus it is not generally used for females.

e) Platelet-rich plasma (PRP)

Many scientific hypotheses have been postulated as to why this may be of benefit however the proof is in the clinical trials. Presently there is no good scientific evidence that platelet-rich plasma(PRP) is of benefit in the management of female hair-loss7.

Some authors show mild benefit however the scientific quality of the data is not yet robust enough or definitive e.g. the treatments are not randomized or they are admixed with other treatments that are already known to be of benefit e.g. minoxidil.

At Paradigm I feel that it is unfair to accept money from patients if there is not a more than reasonable chance that treatment could be of benefit. Thus presently I would not advocate this as a fruitful means of treatment. It may be of benefit in a research setting- but in such circumstances, the research provider will be providing the treatment free of charge.

f) Laser treatment

There is insufficient good quality evidence that laser treatment is of benefit. Many reports have used it but again the quality of evidence that it is of benefit is poor with some reports not producing a benefit perceived by the patient6.

Clinical use may be confounded as laser may be combined with other treatments that are known to be a benefit e.g. topical minoxidil. Thus if laser treatment is to be utilized/sought it should be used on its own (without topical treatments ) in a clinical trial scenario so that its results can be judged on their own merit.

g) Cosmetic camouflage ‘treatments’

Cosmetic camouflage is of course not a treatment but a useful means of disguising the ongoing hair-loss. Thus one can purchase online products which will thicken the calibre of the hair to increase the volume of hair above the scalp egNanogen® fibres.

Alternatively, there are products that minimise the contrast in colour between the hair and the paler underlying skin egTopik®. Such products are very useful if there is this scaffold of hair upon which the products can be applied. With very advanced female pattern hair loss surgical transplantation is required to restore that scaffold.

References

  • Ramos PM 1, Miot HA 1. Female Pattern Hair Loss: a clinical and pathophysiological review. An Bras Dermatol. 2015 Jul-Aug;90(4):529-43.
  • Lucky AW1 et al. A randomized, placebo-controlled trial of 5% and 2% topical minoxidil solutions in the treatment of female pattern hair loss. J Am Acad Dermatol. 2004 Apr;50(4):541-53.
  • van Zuuren EJ1, Fedorowicz Z, Schoones J. Interventions for female pattern hair loss. Cochrane Database Syst Rev. 2016 May 26;(5).
  • Khandpur S1 et al. Comparative efficacy of various treatment regimens for androgenetic alopecia in men. J Dermatol. 2002 Aug;29(8):489-98.
  • Piérard-Franchimont C1et al. Ketoconazole shampoo: effect of long-term use in androgenic alopecia. Dermatology. 1998;196(4):474-7.
  • Kim H1et al. Low-level light therapy for androgenetic alopecia: a 24-week, randomized, double-blind, sham device-controlled multicenter trial. Dermatol Surg. 2013 Aug;39(8):1177-83.
  • Puig CJ1et al. Double-Blind, Placebo-Controlled Pilot Study on the Use of Platelet-Rich Plasma in Women With Female Androgenetic Alopecia. Dermatol Surg. 2016 Nov;42(11):1243-1247.